In honor of Veterans Day, the peer-reviewed journal Women’s Health Issues (WHI) has released a new Special Collection on women veterans’ health, with a focus on mental health. The special collection also highlights recent studies addressing healthcare services, reproductive health and cardiovascular health of women veterans.

“In recent years, we have seen the Veterans Administration working to improve care and health outcomes of women veterans and service members,” said Dr. Chloe Bird, PhD, editor-in-chief of Women’s Health Issues. “The studies published in Women’s Health Issues can help inform efforts to provide the highest quality of care to the growing population of women veterans.”

Women’s Health Issues is the official journal of the Jacobs Institute of Women’s Health, which is based at Milken Institute School of Public Health at the George Washington University. This Special Collection includes articles published after the WHI 2011 special supplement “Health and Health Care of Women Veterans and Women in the Military,” which is available free of charge online.

Studies featured in the Special Collection explore a variety of topics including gender disparities; the impact of co-morbidities and social determinants of health on chronic diseases; and the overall quality, coordination of care, and use of the Veterans Health Administration (VHA) system. The research shows an increased focus on the distinct experiences of women veterans and their overall health risks and quality of care in the VHA. Of particular note are recent findings related to women veterans’ mental health, which was shown in several studies to be closely linked to physical health, and which is a growing area of need for female veterans.

Mental Health & Comorbidities

Mental health conditions explored in the research include posttraumatic stress disorder (PTSD), eating disorders, depression, and other psychiatric disorders. Researchers explored the status of VA mental health care, gender differences, mental health comorbidities, and physical health conditions among women veterans with mental health diagnoses. Three of these five studies focused on women veterans who had been deployed to Iraq and Afghanistan within the past decade. The authors of these studies highlighted several understudied topics, including certain psychiatric disorders such as schizophrenia, the effects of deployment on women veterans’ families, strategies to address treatment access, and the need for gender-sensitive mental healthcare.

Researchers featured in the collection also looked at how mental-health conditions affect reproductive and physical health outcomes for women. Findings from several studies provide additional support for VA initiatives to increase comprehensive care, including increased gender-specific health care services. One study, led by Dr. Shira Maguen, PhD, specifically explored the relationship between PTSD and military sexual trauma (MST), while another study, also led by Dr. Maguen, focused on the likelihood of veterans with mental health disorders such as PTSD, depression, or anxiety receiving an eating disorder diagnosis.

In a third study, Dr. Julie Weitlauf, PhD, and colleagues from the VA Palo Alto Health Care System and the Stanford University School of Medicine in California reported on a their research comparing the rates of cervical cancer screening among women veterans with PTSD or depression and those without. Although psychiatric illness (PTSD or depression) was found to have little effect on use of cervical cancer screening; however, the team, led by did find that women who had one of those diagnoses and were also high users of primary care services were less likely to receive the screening than those who had high use of primary care but no psychiatric illness diagnosis.

An analysis of medical records found that women veterans with mental health diagnoses had a greater prevalence of reproductive health diagnoses, including sexually transmitted infections, compared to women veterans without mental health diagnoses. Those findings were reported in an article by lead author Dr. Beth Cohen, MD, MAS, and colleagues from the San Francisco VA Medical Center and the University of California-San Francisco.

Several of these authors noted that the population of women veterans is growing and projected to continue increasing over the next decade. Currently, women make up about 10 percent of all U.S. veterans and nearly 12 percent of veterans of Operation Enduring Freedom, Operation Iraqi Freedom and Operation New Dawn. By 2035, women are projected to make up 15 percent of all veterans—similar to the current proportion of active duty military personnel that are female.

Meeting the Health Needs of Female Veterans

Also included among the featured articles is a systematic review of recent literature on women veterans’ mental health by Dr. Jennifer J. Runnals, PhD, and colleagues from the Department of Veterans Affairs (VA) and Duke University Medical Center, which appeared in the September-October 2014 edition of Women’s Health Issues. The authors note that since 2000, the VA has witnessed a 33 percent increase in the proportion of women accessing outpatient mental health services, and new female VA users are often younger and show an increased use of VA healthcare services.

“The VA’s commitment to ensuring equitable access to high-quality health care for women veterans of all ages has fueled a burgeoning field of research,” Dr. Runnals and her colleagues explain in their review of 32 recent studies on women veterans’ mental health. Their findings include the following:

For both genders, multiple deployments and post-deployment relationship disruption were associated with increased risk for PTSD.

Barriers to women’s utilization of the VA healthcare system included economic, organizational, and patient factors such as poor health.

Female veterans are particularly likely to suffer from mental health issues. According to the Department of Veterans Affairs, about one-in-five female veterans have post-traumatic stress related to “military sexual trauma,” a catch-all category that includes everything from sexual harassment to rape. Also, women are the fastest growing subset of the homeless-veteran population in America — estimates suggest that about one of every 10 homeless veterans under the age of 45 is now a woman. Moving forward, it will be important to coordinate care, provide effective gender-specific mental health services, and continue to explore the relationship between different mental and physical health conditions.

Recent studies suggest that women veterans may also face greater health challenges compared to civilian women. In 2010, women veterans were more likely than their civilian counterparts to report smoking (18.5 versus 15.5 percent, respectively), being overweight or obese (61.2 versus 55.9 percent, respectively), and having limitations in activity due to physical, mental, or emotional problems (29.3 versus 20.7 percent, respectively). Women veterans were also more likely than civilian women to report having poor mental health on 14 or more days in the past month (18.1 versus 12.5 percent, respectively). Levels of activity limitations and frequent mental distress were also higher than those reported by male veterans (23.3 and 11.1 percent of male veterans, respectively). However, female veterans were more likely than civilian women to have received a past-year preventive visit (76.2 versus 72.0 percent, respectively).

According to a VA report released in February 2014, the top five medical issues for women vets are:

Musculoskeletal (56 percent)

Endocrine/metabolic/nutritional (51 percent)

Mental health/substance use disorders (45 percent)

Cardiovascular disease (37 percent)

Reproductive health (31 percent)

The same report found 57 percent of women vets have some degree of disability related to their military service, versus 46 percent of men. Furthermore, nearly one-third of women veterans reported being exposed to sexual trauma in the military including sexual harassment and assault. These women are at increased risk of major depression, anxiety, PTSD, suicidal thoughts and attempts, and poor quality of life, according to a study published in the Journal of Clinical Psychiatry.

Moving Forward

The growing population of female veterans — and their evolving roles in the military — have introduced new challenges for the VA system and health care providers alike. Women veterans are now more likely than ever to be exposed to a new threat to their health: combat. While they are still officially barred from many combat roles, the nearly 280,000 women who served in the post-9/11 wars in Iraq and Afghanistan were often directly exposed to combat, returning home with combat-related health problems including PTSD and traumatic brain injury.

The VA launched an effort to improve care for women vets in 2008, and the agency has spent more than $1.3 billion to fund research on women’s health, to train doctors, and even build women’s restrooms in its facilities. But the system is still trying to adjust. The VA itself found only one in six female vets understood the health benefits they were eligible for through their military service. And a report from DAV released in September 2014 found that one-third of VA medical centers did not have a gynecologist on staff. A separate investigation, by the Associated Press, found that women were more likely than men to be placed on the VA’s Electronic Wait List than men — a list for patients who can’t be scheduled for an appointment within 90 days.

The authors included in the Special Collection identify several content areas where additional research would be useful to help better understand the needs of women veterans. These areas include best practices for the provision of gender-sensitive care; strategies to address treatment access and retention; and the impact of family reintegration and relationship disruption on women veterans’ mental health. Moving forward, it will be important to coordinate care, provide effective gender-specific mental health services, and continue to explore the relationship between different mental and physical health conditions.